I AM WILL Referral Form

For agencies, hospitals, case managers, social workers, discharge planners, and community partners referring individuals for housing services. Please complete all fields accurately.

Referral Source Information

Referral source name

Agency / organization

Referral source phone number

Referral source email

Client Information

Client name

Client date of birth

Month

Day

Year

Client phone number

Current living situation

Sheltered homeless

Unsheltered homeless

Transitional housing

Living with family/friends

Hospital / facility

Other

Reason for Referral & Client Information

Please describe the reason for referral and include relevant information such as income/payment source, Medicaid or waiver status, mental health or support needs, mobility/ability to care for self, current services/providers, discharge needs, and any other information I AM WILL should know when considering placement.

I confirm that the information provided in this referral is accurate and complete to the best of my knowledge, and that I have obtained the necessary consent to submit this referral on behalf of the individual named above.

I AM WILL Referral Form